Retrograde type A dissection following hybrid supra-aortic endovascular surgery in high risk patients unfit for conventional open repair

Abstract

INTRODUCTION: Hybrid procedures with combined open extra-anatomical supra-aortic bypasses and endovascular surgery are less invasive for patients with complex aortic arch pathology. The aim of this paper is to report patients who developed retrograde Type A aortic dissection following initially successful hybrid endovascular treatment. METHODS: Retrospective review of prospectively collected computerized departmental database. All patients with supra-aortic hybrid endovascular surgery and post-procedure retrograde Type A dissection were identified. Patient demographics, comorbid conditions, perioperative parameters, procedural details and post-operative complications were collected. RESULTS: From May 2005 to March 2014, 163 patients underwent thoracic aortic endovascular procedures at our institution, of which 46 of them had supra-aortic hybrid endovascular repair. Six patients (6/163 (3.6% of all thoracic stentgrafts cases); 6/46 (13% of all supra-aortic hybrid cases), 3 males) developed retrograde Type A aortic dissection. All were elective cases, with 3 chronic dissecting aneurysms and 3 atherosclerotic aneurysms. All had one stage hybrid procedures: 2 patients had carotid-carotid bypass grafts, 1 had carotid-carotid-left subclavian bypass graft, and 3 had bypass grafts from ascending aorta to innominate artery and left carotid artery. Five patients had Cook Zenith thoracic stentgrafts (CookR, Bloomington, USA), and 1 had MedtronicR Valiant stentgrafts (Medtronic Vascular Inc, Santa Rosa, USA). The retrograde Type A dissection occurred with sudden symptoms at day 5, 6, 10, 20, 105 and 128 respectively. There were 3 immediate fatalities and 2 patients treated conservatively deemed unfit for reintervention (one died at 9 month of pneumonia, and one remained alive at 7 months post-complication). One patient underwent successful emergency open surgery and survived. CONCLUSION: Supra-aortic hybrid procedures in treating aortic arch pathology are not protective of retrograde Type A dissection, and patients with this post-operative complication inevitably have poor outcome, even with early diagnosis or treatment is delayed.